Posts Tagged lower limb

[VIDEO] STEPS RehabHub Launch Video – YouTube

Next generation rehabilitation robotic and VR technology delivered by a team of first-class experts.

STEPS is leading the way in rehab technology and is home to an array of cutting edge robotic and virtual reality rehabilitation equipment. This world-leading technology assists with the intensive rehabilitation for people recovering from brain injury, spinal cord injury, strokes and complex trauma injuries.

The latest research in rehabilitation recognises that the best results are achieved through intensity of treatment. By combining the expertise of our clinicians and therapists with state-of-the-art rehabilitation technology, clients can maximise their progress and optimise their outcomes. We are the only place in the UK that gives clients access to rehabilitation robotic and VR technology in a residential setting.

• RehabHub™ – developed in Singapore by Fourier Intelligence, STEPS is the first place in the UK and only the second in Europe to offer clients access to this pioneering upper and lower limb robotic equipment, delivered in partnership with Thor Technologies.

• MindMaze – comprises two revolutionary virtual reality equipment, the MindMotion™ and MindMaze. Both were developed in Switzerland, and this trailblazing VR technology helps clients who have sustained a traumatic brain injury.

• Exoskeletons – STEPS is an assessment centre for the ReWalk™, ExoAtlet II and ReStore™ exoskeletons.

If we think you would benefit from using this specialist equipment as part of your residential rehab programme with us, an assessment will be carried out and a programme for the appropriate equipment will be created.

If you would like to find out more about booking an assessment or trial please contact us- 0114 258 7769.

http://www.stepsrehabilitation.co.uk

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[Abstract] Over-ground robotic lower limb exoskeleton in neurological gait rehabilitation: User experiences and effects on walking ability

Abstract

BACKGROUND: Over-ground robotic lower limb exoskeletons are safe and feasible in rehabilitation with individuals with spinal cord injury (SCI) and stroke. Information about effects on stroke rehabilitees is scarce and descriptions of learning process and user experience is lacking.

OBJECTIVE: The objectives of this study were to describe how rehabilitees learn exoskeleton use, to study effects of exoskeleton assisted walking (EAW) training, and to study rehabilitees’ user experiences.

METHODS: One-group pre-test post-test pre-experimental study involved five rehabilitees with stroke or traumatic brain injury (TBI). Participants in chronic phase underwent twice a week an 8-week training intervention with Indego exoskeleton. Process of learning to walk and the level of assistance were documented. Outcome measurements were conducted with 6-minute and 10-meter walk tests (6 MWT, 10 mWT). User experience was assessed with a satisfaction questionnaire.

RESULTS: Rehabilitees learnt to walk using the exoskeleton with the assistance from 2–3 therapists within two sessions and progressed individually. Three participants improved their results in 10 mWT, four in 6 MWT. The rehabilitees felt comfortable and safe when using and exercising with the device.

CONCLUSION: Indego exoskeleton may be beneficial to gait rehabilitation with chronic stroke or TBI rehabilitees. The rehabilitees were satisfied with the exoskeleton as a rehabilitation device.

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[Abstract] Aquatic Therapy for improving Lower Limbs Function in Post-stroke Survivors: A Systematic Review with Meta-Analysis

ABSTRACT

Background

Lower limb disability is common in chronic stroke patients, and aquatic therapy is one of the modalities used for the rehabilitation of these patients.

Objectives

To summarize the evidence of the effects of aquatic therapy on lower limb disability compared to land-based exercises in post-stroke patients.

Methods

MEDLINE, PsycInfo, CENTRAL, SPORTDiscus, PEDro, PsycBITE, and OT Seeker were searched from inception to January 2019. The search included only randomized clinical trials. Two reviewers independently examined the full text and conducted study selection, data extraction, and quality assessment. Data synthesis was applied to summarize information from the included studies. The quantitative analysis incorporated fixed-effect models.

Results

Of the 150 studies identified in the initial search, 17 trials (629 participants) satisfied the eligibility criteria. Aquatic therapy improved balance based on the Berg Balance Scale (BBS) (standardized mean difference [SMD], 0.72; 95% confidence interval [CI], 0.50–0.94; I2 = 67%) compared with land-based exercises (control). Also, aquatic therapy had a small positive effect on walking speed (SMD, −0.45; 95% CI {-0.71 – (−0.19)}; I2 = 57%), based on the results of the 10-m walking test, compared to controls. Aquatic therapy had a small positive effect on mobility (based on Timed Up and Go), (SMD, −0.43; 95% CI {-0.7-(- 0.17)}; I2 = 71%) compared to land-based exercise (control).

Conclusions

Aquatic therapy had a more positive effect on walking speed, balance, and mobility than land-based exercises. Further research is needed to confirm the clinical utility of aquatic therapy for patients following stroke in the long term.

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[Systematic Review] Brain-Computer Interfaces Systems for Upper and Lower Limb Rehabilitation – Full Text

Abstract

In recent years, various studies have demonstrated the potential of electroencephalographic (EEG) signals for the development of brain-computer interfaces (BCIs) in the rehabilitation of human limbs. This article is a systematic review of the state of the art and opportunities in the development of BCIs for the rehabilitation of upper and lower limbs of the human body. The systematic review was conducted in databases considering using EEG signals, interface proposals to rehabilitate upper/lower limbs using motor intention or movement assistance and utilizing virtual environments in feedback. Studies that did not specify which processing system was used were excluded. Analyses of the design processing or reviews were excluded as well. It was identified that 11 corresponded to applications to rehabilitate upper limbs, six to lower limbs, and one to both. Likewise, six combined visual/auditory feedback, two haptic/visual, and two visual/auditory/haptic. In addition, four had fully immersive virtual reality (VR), three semi-immersive VR, and 11 non-immersive VR. In summary, the studies have demonstrated that using EEG signals, and user feedback offer benefits including cost, effectiveness, better training, user motivation and there is a need to continue developing interfaces that are accessible to users, and that integrate feedback techniques.

1. Introduction

Brain-computer interfaces (BCIs) represent a broad field of research and development from the last few decades. Scientists from all over the world have worked to acquire a deep understanding of BCIs, resulting in rapid and considerable progress in systems, development, and brainwave processing techniques including non-invasive methods such as electroencephalography (EEG) [1]. Most relevantly, useful and novel applications developed in this domain have contributed to the evolution of technology in healthcare [2]; it is clearly evidenced that using a BCI system plays an efficient and “natural” role in the attempt to provide assistance and preventive care to people with neurological disorders [3,4].

The fields where BCIs can be applied are quite promising and diverse. In fact, it is becoming an innovative neurological technology that successfully allows the restoration and improvement of people’s motor and communication abilities [5,6]. According to [7,8,9,10,11,12], its application fields can be divided into communication and control, medical applications, training and education, games and entertainment, monitoring, prevention, detection and diagnosis, intelligent environments, neuromarketing, advertising, security, and authentication. However, this review focuses specifically on examining the applications proposed exclusively as support in rehabilitation processes of the upper and lower limbs of the human body.

For people with partial or total limitation of movement in the upper and lower limbs, using a BCI and classifying an EEG recorded over the sensorimotor cortex in real time gives the possibility of understanding psychological and motor parameters and intentions that allow the reestablishment of communication with the environment [13,14,15]. In short, BCI technology provides direct communication between the brain and an external device, which can assist with numerous diseases [16] such as epilepsy [17], Alzheimer’s disease [18], traumatic brain injuries [19], strokes [20,21], neurological diseases [22], multiple sclerosis [23], and Parkinson’s disease [24]. Indeed, this problem demands innovative advances that counteract the varied impacts that humanity has on a social level, with the economic situation and life of each patient and his or her family coming into play [25].

With the goal of identifying advances and opportunities for improvement in the rehabilitation of upper and lower limbs in the human body, this review includes studies published between 2011 and 2020. In line with the goal of the review, for the included proposals, the devices used for EEG signal acquisition are described, as well as the processing methods within the system, and the BCI applications that support rehabilitation processes in the upper and lower limbs. On the other hand, it was observed that most studies involved BCI systems focused on the upper limbs, and the use of EEG signals and user feedback showed improvements in BCI systems. The objective of this review is to identify the contributions that have been made so far as well as describing opportunities for improvement and limitations that should be taken into account in order to guide future proposals focused on supporting rehabilitation processes of limbs of the human body based on the treatment of EEG signals and user feedback.[…]

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[BLOG] How to normalize gait – Dynamic AFO Foot Drop Brace after stroke

Ankle foot orthoses (AFOs) are frequently prescribed to improve gait deviation and normalize walking patterns in patients with drop foot hemiplegia disorder. In healthy individuals, the functional lower limb shortening which is hip & knee flexion and ankle dorsiflexion mainly achieve toe clearance. By the way, reduction of toe clearance of the affected foot derived from ankle joint disability(foot drop) causes the abnormal movement of knee and hip hike to compensate for the ankle movement. It is a major cause of falls in patients with foot drop disorder.

dynamic-afo-foot-drop-brace-after-stroke

Table of contents

What are Dynamic AFOs?

Conventional AFOs are used to restrict ankle plantarflexion/dorsiflexion movement, thus maintaining the hemiparetic foot in a fixed position of dorsiflexion to facilitate swing. However, this ROM restriction in the ankle joint disrupts the rhythm of gait and increases energy consumption during walking. To alleviate this issue, hinge-applied AFOs were developed to allow some ankle flexibility during the loading response on the affected lower limb, thus slightly reducing the energy cost of hemiparetic gait. It is generally called Dynamic Ankle Foot Orthosis(DAFO). Dynamic Ankle Foot Orthosis(DAFO) generally refers to a custom-made Supra-Malleolar Orthosis fabricated from thin thermoplastic material. It fits the foot intimately and the flexible and thin thermoplastic use means that DAFO can provide circumferential control of the rear and forefoot to maintain a neutral alignment. In the original designs of DAFOs, a ‘neurological’ footplate was often incorporated that consisted of a pad at the peroneal & calf site with dorsiflexing the toes.

These days, the prefabricated DAFOs are common and those are usually applied with shoes to use in daily life especially in outdoor activities.

walk-without-a-fear-of-falling


Who needs a Dynamic Ankle Foot Orthotic (DAFO)?

  • Individuals who have had foot drop after stroke or other neurological deficits as well as nerve injuries resulting in abnormal gait.
  • Those who need to regain the rhythm of gait and increase energy efficiency during walking.
dynamic-ankle-foot-orthotic



Before buying an AFO, check if the orthosis…

  • is tested by experts
  • is easy to wear with shoes
  • supports the ankle and keep dorsiflexed properly
  • keeps the ankle and foot from inverting and dropping
  • allows ankle mobility for a various movement like squat and lunge
  • provides support only where it is needed, swapping unnecessary bulk for a slim fit and cosmetically-appealing look
  • promotes balance improvement through correction of limb asymmetry and hip joint compensation


Neofect STEP Dynamic AFO

Neofect-step_Dynamic-AFO

Neofect STEP is designed to support the ankle and keep the foot dorsiflexed by the Neofect’s expert physical therapist. The main purpose of AFO is to keep the ankle and foot from inverting and dropping at the initial contact and toe-off phase. Also, neutral foot positioning assist ensures a secure heel strike, while ankle joint stabilization corrects varus/valgus positioning in mid-stance. Dynamic dorsiflexion through the elastomer ankle joint ensures toe clearance during the swing phase. This can be caused by nerve injury, muscle or nerve disorders, brain or spinal cord disorders. With its flexible/supportive hinge component, an AFO helps individuals walk more naturally while lifting the foot and keeping the ankle in alignment.

neofect-step-afo-size-chart

Foot drop causes the toes to drag on the ground, creating the need for gait changes to compensate to clear the foot. It’s forcefully making you use those muscles that have atrophy, so you can see a difference when not wearing it. Also, it provides enough range of motion to still be able to squat, lunge and perform a higher level of balance. And the foot-plate supports approximately  of foot length. It retains flexibility and prevents paresthesia in the toes.

Neofect STEP provides a strong, lightweight solution to support people with a range of walking disorders caused by a variety of neurological and musculoskeletal disorders.

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[WEB] Specialist rehab facility reveals new cutting-edge rehab tech to improve client outcomes

By Sarah Sarsby

STEPS Rehabilitation RehaHub image

Sheffield-based STEPS Rehabilitation, a specialist facility that delivers intensive rehabilitation for people recovering from brain injury, spinal cord injury, strokes and complex trauma injuries, is now home to “cutting-edge” rehabilitation equipment.

The specialist facility has launched STEPS RehaHub, which has become the first place in the UK to provide clients with access to “word-class” robotics and virtual reality (VR) technology.

The suite of assistive technology focuses on upper and lower limb robotic therapy, as well as cognitive feedback and training for a complete solution for neurorehabilitation.

It comes after STEPS Rehabilitation has been working with innovators in Singapore and Switzerland.Advertisement | Continue story below


Fourier Intelligence is a Singapore-based technology company that develops pioneering exoskeleton and rehabilitation robotics. By combining the expertise and experience of researchers, therapists, and patients, the company excels in developing new robotic solutions to support the rehabilitation process and lives of patients.

“We’re offering this new tech in conjunction with Thor Assistive Technologies,” reveals STEPS Rehabilitation Business Development Director Jules Leahy. “We’ve been working with the founder, Stephen Ruffle, for a while now with ReWalk Exoskeleton, and we know just how much clients can progress with the assistance of the right technology.”

Stephen explains: “The RehabHub is a suite of rehab technology which focus on both upper and lower limb robotic therapy, as well as cognitive feedback and training, providing a complete solution for neurorehabilitation.

“The unique and innovative ‘Force Feedback’ technology creates an immersive game environment which facilitates highly effective rehabilitation. Use of the technology naturally encourages repetition and intensity which improves client engagement and outcomes.

“As the devices are all linked, it enables client-against-client gaming competition, which enhances motivation and stamina. The technology also provides therapists and clients with performance feedback which tracks client progress and helps shape individual rehabilitation programmes.”

The suite of equipment includes the latest in cycle motion, arm, wrist, finger, and ankle rehabilitation robotics.

“Clients can access the pioneering OTParvos alone or in conjunction with the HandyRehab,” comments STEPS Rehabilitation Clinical Director Toria Chan. “These amazing pieces of kit used together provide a portable intelligent solution for therapy, supporting the functional rehabilitation of the upper limb, fine motor skills of the fingers, hand-eye coordination and cognitive ability.

“They allow clients to undertake training using everyday objects with the assistance of a lightweight robotic glove, with quantifiable data being recorded in real time enhancing the rehabilitation process. We can’t wait to see the results!”

As well as being the first UK Fourier Intelligence Rehabilitation Hub, the specialist rehabilitation facility is also now one of two UK facilities offering clients access to the “revolutionary” MindMaze VR rehabilitation technology.

Developed in Switzerland, MindMaze equipment helps clients who have sustained a traumatic brain injury.

“We’ve been carefully exploring what VR technology is out there, and the portfolio of MindMaze equipment is truly impressive,” adds Toria. “It includes the MindMotion GO, a first-of-its-kind mobile neurorehabilitation therapy system that comes with a large variety of gamified engaging activities covering motor and task functions. Thanks to the motivating effects of the 3D virtual environment, early results suggest an increased client engagement and adherence to therapy.”

The MindPod Dolphin is an engaging animated gaming experience that promotes the recovery of motor skills and cognitive function.

Toria continues: “The dolphin has been designed by Pixar animators no less! It comes with an anti-gravity vest that de-weights the arm and trains fine-motor control of the upper-limb by encouraging continuous exploration of its immersive oceanic environment.”

Now, STEPS is in discussions to collaborate with the Advanced Wellbeing Research Centre (AWRC) at Sheffield Hallam University to undertake new research that will investigate and explore the benefits of this new rehabilitation technology. The specialist centre at the university is dedicated to improving the health and wellbeing through movement, harnessing world-class research and design.

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[ARTICLE] Robotic-assisted gait rehabilitation following stroke: a systematic review of current guidelines and practical clinical recommendations – Full Text PDF

INTRODUCTION: Stroke is the third leading cause of adult disability world-wide, and lower extremity motor impairment is one of the major determinants of long-term disability. Although robotic therapy is becoming more and more utilized in research protocols for lower limb stroke rehabilitation, the gap between research evidence and its use in clinical practice is still significant. The aim of this study was to determine the scope, quality, and consistency of guidelines for robotic lower limb rehabilitation after stroke, in order to provide clinical recommendations.


EVIDENCE ACQUISITION: We systematically reviewed stroke rehabilitation guideline recommendations between January 1st, 2010 and October 31th, 2020. We explored electronic databases (n=4), guideline repositories and professional rehabilitation networks (n=12). Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and brief syntheses were used to evaluate and compare the different recommendations, considering only the most recent version.


EVIDENCE SYNTHESIS: From the 1219 papers screened, ten eligible guidelines were identified from seven different regions/countries. Four of the included guidelines focused on stroke management, the other six on stroke rehabilitation. Robotic rehabilitation is generally recommended to improve lower limb motor function, including gait and strength. Unfortunately, there is still no consensus about the timing, frequency, training session duration and the exact characteristics of subjects who could benefit from robotics.


CONCLUSIONS: Our systematic review shows that the introduction of robotic rehabilitation in standard treatment protocols seems to be the future of stroke rehabilitation. However, robot assisted gait training (RAGT) for stroke needs to be improved with new solutions and in clinical practice guidelines, especially in terms of applicability.

Full Text PDF

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[ARTICLE] Goal attainment: a clinically meaningful measure of success of Botulinum Toxin-A treatment for lower limb spasticity in ambulatory patients – Full Text

Abstract

Objective

The objectives of this study were: (1) to evaluate whether Botulinum toxin type A (BoNT-A) treatment for lower limb spasticity leads to patient goal attainment and identify factors associated with positive goal attainment, and (2) to assess the effect of BoNT-A treatment on patients’ gait.

Design

Retrospective cohort study between June 2014 and February 2019.

Setting

Public outpatient spasticity clinic in a tertiary hospital.

Participants

Thirty patients (50% female, average age 50.5 years) with lower limb spasticity of heterogenous aetiologies (96.7% cerebral ± spinal origin and 3.3% isolated spinal origin). 73.3% of patients had previously received BoNT-A treatment.

Interventions

BoNT-A injection to lower limb muscles.

Main outcome measures

The primary outcome measure was goal attainment measured using the Goal Attainment Scale (GAS). The Modified Ashworth Scale (MAS) was used to assess spasticity. Gait was characterised by spatiotemporal parameters.

Results

Fifty-six treatment episodes were analysed and showed BoNT-A treatment resulted in a significant reduction in spasticity (pre-treatment MAS = 3.18±0.73; post-treatment MAS = 2.27±0.89, p<0.001) with no associated change in gait parameters. Logistic regression revealed most patients (74.1%) achieved all of their goals with younger patients having a high likelihood of goal attainment regardless of their gait profile identified by latent profile analysis of the gait parameters. Patients considered to have a low functioning gait profile demonstrated a significantly greater likelihood of goal attainment than the patients of the other gait profiles combined (OR= 45.6, 95% CI= 1.3 to 1602.1; p=0.036). Chronic spasticity, pre-treatment severity of spasticity (MAS) and its reduction were not associated with likelihood of goal attainment.

Conclusion

The success and efficacy of BoNT-A treatment in improving patient perceived gait quality and reducing the negative symptoms of spasticity was best measured using the GAS. The study emphasises the importance of measuring patient goals as a clinical outcome. Gait parameters were most informative when used collectively to classify patients on the basis of their overall gait profile which assisted in identifying differences between patients’ likelihood of goal attainment following treatment.

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Spasticity, a sequelae of numerous neurological disorders, is characterised by a velocity dependent increase in muscle tone that results in resistance to passive movement, involuntary muscle spasms and contractions (1, 2). Lower limb spasticity can result in disabling consequences including pain, spasm, altered posture, deformity of the foot and ankle, and impairment of gait and mobility (3, 4). The impact on gait and mobility is associated with loss of function and independence, higher morbidity including falls and fracture (3) and premature residential aged care placement (5-7). Prevention and management of lower limb spasticity and sequelae is therefore an important focus of neurological rehabilitation.

Previous research has demonstrated the positive effects of focal injections of the neurotoxic protein botulinum toxin A (BoNT-A) in treating spasticity and it is now a widely accepted treatment modality (8-18). Studies investigating the effect of BoNT-A on lower limb spasticity have concentrated on outcomes including gait, safe and independent mobility, and activities of daily living (3, 8-10, 13-15, 17, 19-27). To date, the evidence regarding the benefit of BoNT-A mediated reduction in lower limb spasticity on functional outcomes remains inconsistent (20).

In clinical practice the indications and objectives for BoNT-A treatment of lower limb spasticity are diverse and patient specific, as are the patient’s priorities and expectations of the treatment. Rehabilitation-centred frameworks should therefore include a meaningful patient focused purpose for BoNT-A treatment, beyond reducing spasticity itself (28), by identifying patient needs, priorities and goals and tailoring treatment towards addressing and achieving these.

Few previous studies examining BoNT-A treatment for lower limb spasticity have reported the nature of patient goals, examined goal attainment outcomes or investigated factors associated with the likelihood of goal attainment (15, 29-31). A better understanding of such relationships is of clinical value, may guide patient selection and help predict positive treatment outcomes. Hence, the primary aim of this study was to evaluate the attainment of patients’ self-identified treatment goals, and factors associated with the likelihood of patient goal attainment. A secondary aim was to assess the effect of BoNT-A treatment on the gait of patients with lower limb spasticity.[…]

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[Abstract] Effects of motor imagery training on lower limb motor function of patients with chronic stroke: A pilot single‐blind randomized controlled trial

Abstract

Aims

This pilot study aimed to evaluate the effects of motor imagery training on lower limb motor function of stroke patients.

Background

Motor imagery training has played an important role in rehabilitation outcomes of stroke patients.

Methods

In this pilot randomized controlled trial 32 stroke patients were randomly divided into experimental and control groups from January to June 2017. Patients in both groups received conventional neuro‐rehabilitation five times a week in 3‐h segments for 6 weeks. Patients in the experimental group underwent an additional 20 min of motor imagery training. Measures were evaluated by motor function of the lower extremity, activities of daily living and balance ability.

Results

The outcomes significantly improved by motor imagery training were the Fugl‐Meyer Assessment of the lower extremity, the Functional Independence Measure dealing with transfers and locomotion, and the Berg Balance Scale.

Conclusion

Motor imagery training could be used as a complement to physical rehabilitation of stroke patients. Our findings may be helpful to develop nursing strategies aimed at improving functional ability of stroke patients and thus enhancing their quality of life.

Summary statement

What is already known about this topic?

  • Lower extremity dyskinesia is among the most common complications that significantly limit the patient’s activities of daily living. Motor imagery training, a safe and cost‐efficient technique, may be used as a complement to physical rehabilitation of stroke patients.
  • Evidence suggests that motor imagery training is effective in upper limb recovery after stroke.
  • There is limited evidence of the effectiveness of motor imagery training on lower limb motor functions of patients with chronic stroke.

What this paper adds?

  • Motor imagery training can be incorporated into conventional therapy among individuals by rehabilitation specialist nurses with sufficient experience of motor imagery training, but substantial resources are needed.
  • Six‐week motor imagery training resulted in a significant improvement in the motor performance of lower limbs in patients with stroke.
  • Further study is needed to modify and optimize the present programme and should be focused on enabling more stroke patients to benefit from motor imagery training.

The implications of this paper:

  • The addition of motor imagery training to the conventional neuro‐rehabilitation can significantly promote the recovery of motor performance of lower limbs in stroke patients, thus reducing long‐term disability and associated socio‐economic burden.
  • The findings of this pilot study may be helpful to develop nursing strategies aimed at improving functional ability and consequently the quality of life of stroke patients.
  • Nurses can learn the motor imagery training as a technique for practising psychomotor nursing skills.

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[ARTICLE] A Depth Camera–Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study – Full Text

Figure 1. A participant experiencing Stomp Joy

Abstract

Background:The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed.

Objective:We developed a depth camera–based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy.

Methods:We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded.

Results:This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported.

Conclusions:Stomp Joy is an effective depth camera–based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size.

Introduction

There are 800,000 new or recurring incidences of stroke annually in the United States; the number is rising as the population ages. More than half of stroke survivors live with at least one type of motor impairment [1]. In China, there are approximately 2 million incidences of a stroke every year. Among these stroke survivors, 70% to 80% cannot live independently as a result of multiple impairments, such as motor impairments with loss of strength, stereotypic movements, changes in muscle tone, and limitations in activities [2]. For many patients with stroke, balance and weight shift management constitute a risk for secondary injury. Lower extremity (LE) functional deficits in patients after stroke have aroused a great amount of attention because they play a vital role in stroke survivors’ quality of life [1,2]. Although stroke (new and recurring) remains prevalent, the number of available therapists is far from meeting the need, since the development of physical therapy has still not matured [3,4]. Rehabilitation technologies have the potential to increase the intensity and dose of rehabilitation, improve access to rehabilitation, reduce the workload of therapists, measure and provide feedback about performance and recovery, and engage and motivate patients [57]. Evidence-based medicine shows that high-intensity, repetitive, task-specific training tends to benefit patients greatly [8]. However, it is difficult to implement high-intensity, repetitive, task-specific training in a real clinical setting for a variety of reasons, including limited necessary resources and difficulty maintaining patients’ interest. Therefore, virtual reality–based gaming systems have become popular in medical rehabilitation and can be used as a novel alternative therapy method for motor recovery after stroke.

Kinect (Microsoft) is the leader in commercially available low-cost virtual reality (VR) hardware. This is because most of the Kinect’s games are aimed at the average person, and there are many more games designed by research teams for people with stroke, especially for upper limb motor function. However, there are few games focused on lower limb motor function [9]. VR, also known as immersive multimedia or computer-simulated reality, is a computer technology that replicates an environment, real or imagined, and simulates the user’s physical presence and environment to allow for user interaction and immersion. Virtual realities artificially create sensory experience, which can include sight, touch, hearing, and smell [10]. VR systems consist of a development platform, display system, interaction system, and integrated control system [11]. To realize the complete information interaction between computers and humans, normally we need some external device or devices to record the user’s movements. Among the kinds of external devices are force or tactile feedback systems, position trackers, data gloves or 6-degrees-of-freedom space mice, joysticks, and the Kinect sensor [1113]. Kinect allows users to play without holding a game controller, which means they will not be bothered by wearing sensors that can be intrusive. This also saves time. Zhu et al [14] showed that the Kinect motion capture system was reliable and that the correlation coefficient of the dynamic track was quite good. A large number of clinical studies have shown that the accuracy of the Kinect somatosensory technology sensor for posture control and evaluation can fully meet the needs of body motion evaluation [1517]. Eltoukhy et al [18] indicated that Kinect-based assessment might provide clinicians a simple tool to simultaneously assess reach distances while developing a clearer understanding of lower extremity movement patterns. Park et al [19] showed that the use of additional VR training with the Xbox Kinect gaming system was an effective therapeutic approach for improving motor function during stroke rehabilitation.

However, these systems were not specifically developed for patients after stroke, and those training sessions might produce multiple effects [20]. Those studies did not assess the flow experience of users, and few of them conducted a clinical randomized controlled trial. To address these issues, we developed a depth camera–based game, Stomp Joy, specifically for the lower limbs of patients with stroke. We also applied two principles of game design that are highly relevant to rehabilitation. The aim of this study was twofold: (1) develop a depth camera–based, task-oriented rehabilitation game for patients with stroke and (2) assess its usability and conduct a pilot study for stroke survivors’ LE rehabilitation.[…]

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